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Chapter 11 General and Local Anesthetics Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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1 Chapter 11 General and Local Anesthetics Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

2  Drugs that reduce or eliminate pain by depressing nerve function in the central nervous system (CNS) and peripheral nervous system (PNS) Anesthetics 2Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

3  A state of depressed CNS activity  Two types  General anesthesia  Local anesthesia  Balanced anesthesia Anesthesia 3Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

4  Drugs that induce a state in which the CNS is altered to produce varying degrees of:  Pain relief  Depression of consciousness  Skeletal muscle relaxation  Reflex reduction General Anesthetics 4Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

5  Inhalational anesthetics  Volatile liquids or gases that are vaporized in oxygen and inhaled  Parenteral anesthetics  Administered intravenously General Anesthetics (cont’d) 5Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

6 Classroom Response Question The nurse anesthetist is planning to use balanced anesthesia during a surgical procedure. A characteristic of this type of anesthesia is the A.administration of minimal doses of multiple anesthetic drugs. B.administration of inhaled anesthetics. C.IV administration of anesthetics. D.administration of anesthetics to cause muscle relaxation. 6Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

7  Used to induce anesthesia  Inhaled gas  nitrous oxide (“laughing gas”)  Inhaled volatile liquids  enflurane (Ethrane)  halothane (Fluothane)  isoflurane (Forane)  methoxyflurane (Penthrane)  Others Inhaled Anesthetics 7Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

8  Used:  To induce or maintain general anesthesia  To induce amnesia  As an adjunct to inhalation-type anesthetics Parenteral Anesthetics 8Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

9  etomidate (Amidate)  ketamine (Ketalar)  methohexital (Brevital)  propofol (Diprivan)  thiopental (Pentothal) Parenteral Anesthetics (cont’d) 9Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

10  Sedative-hypnotics  Barbiturates (pentobarbital, secobarbital)  Benzodiazepines (diazepam, midazolam)  hydroxyzine  promethazine  Opioid analgesics  fentanyl, sufentanil, meperidine, morphine Adjunct Drugs 10Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

11  Neuromuscular blocking drugs (NMBDs)  Depolarizing drugs (succinylcholine, d-tubocurarine)  Nondepolarizing drugs (pancuronium, vecuronium)  Anticholinergics  atropine, glycopyrrolate, scopolamine Adjunct Drugs (cont’d) 11Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

12  Varies according to drug  Overton-Meyer theory  Overall effect  Orderly and systematic reduction of sensory and motor CNS functions  Progressive depression of cerebral and spinal cord functions Mechanism of Action 12Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

13 Classroom Response Question When assessing a patient under general anesthesia, which change to organ systems does the nurse expect? A.Nystagmus B.Skeletal muscle constriction C.Hypertension D.Decreased intracranial pressure 13Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

14  General anesthetics are used during surgical procedures to produce:  Unconsciousness  Skeletal muscular relaxation  Visceral smooth muscle relaxation  Rapid onset; quickly metabolized  Also used in electroconvulsive therapy treatments for depression Indications 14Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

15  Vary according to dosage and drug used  Sites primarily affected  Heart, peripheral circulation, liver, kidneys, respiratory tract  Myocardial depression is commonly seen Adverse Effects 15Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

16  Malignant hyperthermia  Occurs during or after general anesthesia or use of the NMBD succinylcholine  Sudden elevation in body temperature (greater than 104° F)  Tachypnea, tachycardia, muscle rigidity  Life-threatening emergency  Treated with cardiorespiratory supportive care and dantrolene (skeletal muscle relaxant) Adverse Effects (cont’d) 16Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

17 Classroom Response Question During surgery, the anesthetist notes that the patient’s heart rate is gradually increasing and becoming more irregular, the patient’s blood pressure is becoming unstable, and the patient is starting to sweat profusely. What other assessment should the anesthetist note immediately? A.Pupillary reactions B.Respiratory effort C.Temperature D.Urinary output 17Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

18  Also called conscious sedation and procedural sedation  Combination of an IV benzodiazepine (e.g., midazolam) and an opiate analgesic (e.g., fentanyl or morphine)  Anxiety and sensitivity to pain are reduced, and patient cannot recall the procedure  Preserves the patient’s ability to maintain own airway and to respond to verbal commands Moderate Sedation 18Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

19  Used for diagnostic procedures and minor surgical procedures that do not require deep anesthesia  Rapid recovery time and greater safety profile than general anesthesia Moderate Sedation (cont’d) 19Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

20 Classroom Response Question Which statement regarding conscious sedation does the nurse identify as being accurate? A.The intravenous route of drug administration is commonly used in pediatric patients to provide conscious sedation. B.Mild amnesia is a common effect of midazolam. C.Patients receiving conscious sedation must be intubated with an endotracheal tube. D.Effects of propofol include relief of anxiety and pain. 20Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

21  Also called regional anesthetics  Used to render a specific portion of the body insensitive to pain  Interfere with nerve impulse transmission to specific areas of the body  Do not cause loss of consciousness Local Anesthetics 21Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

22  Topical  Applied directly to skin or mucous membranes  Creams, solutions, ointments, gels, ophthalmic drops, powders, suppositories  Parenteral  Injected intravenously or into the CNS by various spinal injection techniques Local Anesthetics (cont’d) 22Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

23  Spinal or intraspinal  Intrathecal  Epidural  Infiltration  Nerve block  Topical Types of Local Anesthesia 23Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

24  lidocaine (Xylocaine)  mepivacaine (Carbocaine)  procaine (Novocain)  tetracaine (Pontocaine)  Others Parenteral Anesthetics 24Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

25  First, autonomic activity is lost  Then pain and other sensory functions are lost  Last, motor activity is lost  As local drugs wear off, recovery occurs in reverse order (motor, sensory, then autonomic activity are restored) Drug Effects: Paralysis 25Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

26  Local anesthetics are used for:  Surgical, dental, and diagnostic procedures  Treatment of certain types of chronic pain  Spinal anesthesia: to control pain during surgical procedures and childbirth  Local anesthetics are given by:  Infiltration anesthesia  Nerve block anesthesia Indications 26Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

27  Infiltration anesthesia  Minor surgical and dental procedures  Injection of the anesthetic solution intradermally, subcutaneously, submucosally, or intramuscularly across the path of nerves supplying target area  May be given in a circular pattern around operative area Indications (cont’d) 27Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

28  Infiltration anesthesia and epinephrine  Some local anesthetics used for infiltration or nerve block are combined with vasoconstrictors To prevent systemic absorption of anesthetic To help confine local anesthetic to injected area To reduce local blood loss during procedure Indications (cont’d) 28Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

29  Nerve block anesthesia  Used for surgical, dental, and diagnostic procedures  Also used for therapeutic management of pain  The anesthetic drug is injected directly into or around the nerve trunks or nerve ganglia that supply the area to be numbed Indications (cont’d) 29Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

30  Usually limited  Adverse effects result if:  Inadvertent intravascular injection  Excessive dose or rate of injection  Slow metabolic breakdown  Injection into highly vascular tissue  “Spinal headache” Adverse Effects 30Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

31 Classroom Response Question When teaching a patient about spinal headaches, which statement will the nurse include? A.Spinal headaches can be prevented with bed rest after the epidural procedure. B.Patients who have a spinal headache should have very limited fluid intake. C.A graft of skin from the patient’s hand can be used to seal the leaking area causing the headache. D.High Fowler’s positioning should be used for patients who have a spinal headache. 31Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

32  Also known as NMBDs  Prevent nerve transmission in certain muscles, resulting in muscle paralysis  Used with anesthetics during surgery Neuromuscular Blocking Drugs 32Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

33  When used during surgery, artificial mechanical ventilation is required  These drugs paralyze respiratory and skeletal muscles  Patient cannot breathe on his or her own  Do not cause sedation or pain relief  Patient may be paralyzed yet conscious Neuromuscular Blocking Drugs (cont’d) 33Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

34  Depolarizing drugs  Nondepolarizing drugs  Short-acting  Intermediate-acting  Long-acting Neuromuscular Blocking Drugs (cont’d) 34Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

35  Succinylcholine  Works similarly to neurotransmitter acetylcholine (ACh), causing depolarization  Metabolism is slower than ACh, so as long as succinylcholine is present, repolarization cannot occur  Result: flaccid muscle paralysis NMBDs: Depolarizing Drugs 35Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

36  Short-acting  mivacurium (Mivacron)  Intermediate-acting  atracurium (Tracrium)  vecuronium (Norcuron)  rocuronium (Zemuron)  Long-acting  pancuronium (Pavulon)  doxacurium (Nuromax) NMBDs: Nondepolarizing Drugs 36Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

37  Prevent ACh from acting at neuromuscular junctions  Nerve cell membrane is not depolarized; muscle fibers are not stimulated  Skeletal muscle contraction does not occur NMBDs: Nondepolarizing Drugs (cont’d) 37Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

38  First sensation is muscle weakness, followed by total flaccid paralysis  Small, rapidly moving muscles affected first (fingers, eyes), then limbs, neck, trunk  Finally, intercostal muscles and diaphragm affected, resulting in cessation of respirations  Recovery of muscular activity usually occurs in reverse order  Transient muscle fasciculations may result in later muscle soreness Neuromuscular Blocking Drugs 38Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

39  Main use: facilitating controlled ventilation during surgical procedures  Endotracheal intubation (short-acting)  To reduce muscle contraction in an area that needs surgery  Diagnostic drugs for myasthenia gravis  Other uses NMBDs: Indications 39Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

40  Few when used appropriately  May cause:  Hypotension (blockade of autonomic ganglia)  Tachycardia (blockade of muscarinic receptors)  Hypotension (release of histamine)  Effects vary according to site NMBDs: Adverse Effects 40Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

41  Respiratory muscle paralysis occurs with these drugs  Emergency ventilation equipment must be immediately available NMBDs: Safety 41Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

42 Classroom Response Question A patient is to receive a neuromuscular blocking drug while on mechanical ventilation. While the patient is receiving this medication, the nurse should expect the patient to be: A.sedated. B.resisting the ventilator. C.awake but unable to move. D.pain free. 42Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

43  Overdose causes prolonged paralysis requiring prolonged mechanical ventilation  Cardiovascular collapse may occur  Several conditions may increase sensitivity to NMBDs NMBDs: Overdose 43Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

44  Always assess past history of surgeries and response to anesthesia  Assess past history, allergies, medications  Assess use of alcohol, illicit drugs, opioids Nursing Implications 44Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

45  Assessment is vital during preoperative, intraoperative, and postoperative phases  Vital signs  Baseline lab work, ECG  Oxygen saturation  ABCs (airway, breathing, circulation)  Monitor all body systems Nursing Implications (cont’d) 45Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

46  Each perioperative phase has its own complex and very specific nursing actions  Provide preoperative teaching about the surgical procedure and anesthesia Nursing Implications (cont’d) 46Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

47  Perform close and frequent observation of the patient and all body systems  During a procedure, monitor vital signs, ABCs  Watch for sudden elevations in body temperature, which may indicate malignant hyperthermia Nursing Implications (cont’d) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.47

48 Classroom Response Question A patient in the intensive care unit will be receiving a neuromuscular blocking drug. Which piece of equipment is essential to have nearby when the nurse initiates this therapy? A.Defibrillator B.Sphygmomanometer C.Mechanical ventilator D.Oxygen source 48Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

49  During recovery, monitor for cardiovascular depression, respiratory depression, and complications of anesthesia  Implement safety measures during recovery, especially if motor or sensory loss occurs because of local anesthesia Nursing Implications (cont’d) 49Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

50  Reorient patient to his or her surroundings  Teach the patient about postoperative turning, coughing, deep breathing Nursing Implications (cont’d) 50Copyright © 2014 by Mosby, an imprint of Elsevier Inc.


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